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Professional assertiveness can enable the healthcare provider to confidently share their expertise without seeming authoritarian to the patient. Professional assertiveness is an interpersonal communication skill that helps express opinions or knowledge while respecting similar competencies in others. For healthcare providers, this compares to sharing scientific or professional knowledge with their patients while respecting their person, ideas, and autonomy. Professional assertiveness also connects the patient's beliefs and values with actual scientific evidence and healthcare system constraints. The definition of professional assertiveness might be easy to understand, but it remains challenging to apply in clinical practice. In this essay, we hypothesize that the practical difficulties healthcare providers encounter with assertive communication stem from their misunderstanding of this style.

Background Expertise involves a high level of knowledge or skill in a specific area. Medical expertise encompasses knowledge, technical skills, and socio-cognitive skills like clinical reasoning, essential for accurate diagnosis and treatment. Although traditionally seen as technicians, anaesthesiologists are vital cognitive experts in the operating room, where situational awareness and decision-making are crucial in high-risk, fast-paced situations prone to cognitive bias. Properly defining the cognitive aspects of anaesthetic expertise is challenging, hindering research and educational consistency. This study aims to identify, appraise, and synthesize how expertise within clinical reasoning among anaesthetists is conceptualized in the literature. Methods We will search Medline, Embase, and Cochrane databases for peer-reviewed papers up to July 1, 2024, focusing on anaesthesiology, expertise, and clinical reasoning. Our searches will include related terms and citations. According to the PRISMA flow chart, two reviewers will independently screen titles, abstracts, and full texts against inclusion criteria, excluding papers focusing solely on technical expertise. A third reviewer will resolve any disagreements. Information on references, article type, research area, anaesthetic field, and conceptualizations of clinical reasoning expertise will be extracted using a standardized form. To achieve an operational synthesis, a two-stage qualitative analysis will be conducted. The first stage involves a comprehensive semantic analysis to identify patterns and thematic clusters. The second stage follows the Thomas and Harden approach for formal thematic synthesis, using codes to develop categories that lead to descriptive themes. The resulting multi-layered tree structure will ultimately enable generating analytical themes. Discussion A clear concept synthesis of clinical reasoning expertise among anaesthetists could enhance research, education, and guidelines, thereby improving patient safety. The proposed systematic review and qualitative thematic synthesis aims to clarify this complex concept by analysing data from diverse scientific literature. A broad research strategy will be employed, followed by rigorous qualitative analysis, including semantic analysis and thematic synthesis, to capture the multifaceted nature of clinical reasoning. This study will be the first to propose a global approach, facilitating improved pedagogical interventions and integrating insights into AI models for enhanced training and clinical decision-making. Systematic review registration PROSPERO registration number CRD42024510184.

Simulation has become an essential pedagogical tool in health professions education, traditionally valued for its ability to approximate clinical practice. Higher simulation fidelity is often assumed to directly enhance learner engagement and improve educational outcomes; however, this assumption oversimplifies a complex relationship. Fidelity is multidimensional, encompassing physical, emotional, and contextual dimensions, as well as qualitative and quantitative considerations, each influencing learners’ perception of realism in distinct ways. Engagement is shaped not only by these dimensions of fidelity but also by intrinsic factors such as motivation, prior experience, stress, and emotional resilience, and by extrinsic factors including instructional design, facilitation, debriefing, and psychological safety. A central mediator in this process is the fiction contract, an implicit agreement that enables learners to suspend disbelief and engage authentically despite inherent limitations in realism. Technological sophistication alone does not necessarily translate into greater educational impact. Rather, fidelity should be intentionally aligned with learning objectives: advanced patient simulators may support procedural training, standardized patients may enhance communication skills, and task trainers may optimize focused psychomotor practice. This viewpoint advocates for a goal-oriented, multimodal approach that redefines high-fidelity simulation not as the pursuit of maximum realism, but as the deliberate alignment of fidelity with pedagogy to optimize learner engagement and educational effectiveness.

Purpose There is an elevated incidence of hypoxemia during the airway management of the morbidly obese. We aimed to assess whether optimizing body position and ventilation during pre-oxygenation allow a longer safe non-hypoxic apnea period (SNHAP). Methods Fifty morbidly obese patients were recruited and randomized for this study. Patients were positioned and preoxygenated for three minutes in the ramp position associated with spontaneous breathing without additional CPAP or PEEP (RP/ZEEP group) or in the reverse Trendelenburg position associated with pressure support ventilation mode with pressure support of 8 cmH 2 O and an additional 10 cmH 2 O of PEEP while breathing spontaneously (RT/PPV group) according to randomization. Results The SNHAP was significantly longer in the RT/PPV group (258.2 (55.1) vs. 216.7 (42.3) seconds, p  = 0.005). The RT/PPV group was also associated to a shorter time to obtain a fractional end-tidal oxygen concentration (FEtO 2 ) of 0.90 (85.1(47.8) vs 145.3(40.8) seconds, p  < 0.0001), a higher proportion of patients that reached the satisfactory FEtO 2 of 0.90 (21/24, 88% vs. 13/24, 54%, p  = 0.024), a higher FEtO 2 during preoxygenation (0.91(0.05) vs. 0.89(0.01), p  = 0.003) and a faster return to 97% oxygen saturation after ventilation resumption (69.8 (24.2) vs. 91.4 (39.2) seconds, p  = 0.038). Conclusion In the morbidly obese population, RT/PPV, compared to RP/ZEEP, lengthens the SNHAP, decreases the time to obtain optimal preoxygenation conditions, and allows a faster resuming of secure oxygen saturation. The former combination allows a more significant margin of time for endotracheal intubation and minimizes the risk of hypoxemia in this highly vulnerable population. Trial registration NCT02590406, 29/10/2015.

Recently, the nociceptive level index (NOL) was shown to more specifically and sensitively detect noxious stimuli during anesthesia, in comparison to previous methods that relied on such parameters as heart rate (HR) and mean blood pressure (MAP). An ongoing study (NCT#03410485) evaluates the intraoperative combination of both NOL and bispectral (BIS) indices to improve quality of recovery after colorectal surgery. Our ethical committee (REB approval #CER15083) initially agreed on an interim analysis of the data from the first 30 patients. More specifically, this present report analyzed all the intravenous phenylephrine (PE) boluses administered during anesthesia as part of our study protocol to see whether they had a significant impact on NOL values as well as other parameters: HR, MAP, BIS index. For this trial, remifentanil and phenylephrine were given in both groups based on a specific algorithm. All study parameters were recorded electronically. Our analysis for the present specific outcome evaluated NOL index for 30 s before the intravenous PE bolus (1 µg kg−1) was given and until 5 min afterwards. The average NOL values after PE bolus, as well as MAP, HR and BIS indices, were recorded and analyzed. A total of 178 events of PE boluses were identified for 28 patients (two were excluded). Median baseline NOL was 3 (1.8–8.3) CI 95% 5.7–8.7; post-PE bolus: 5.3 (2.7–9.9) (95% CI 6.6–8.9; Wilcoxon matched-pairs signed rank test (WMPSRT), P = 0.0003). When analyzing delta NOL (difference between pre- and post-PE bolus in NOL values) for each patient, the median delta NOL was 2.9 (1.2–6.1) (95% CI 3.6–5.5) with 95% of the subjects keeping a delta NOL under 10. MAP and HR values showed expected significant variations after PE bolus: a slight increase and slight decrease, respectively. BIS index values did not change after PE bolus. Our present results demonstrate that intravenous phenylephrine boluses of 1 µg kg−1 had the expected impact on hemodynamic parameters: a significant but very slight increase in MAP and decrease in HR, which might lack clinical relevance. Our report also demonstrates that these same phenylephrine boluses induce a statistically significant increase of the NOL index which does not seem to have much of a clinical relevance for the novel NOL index used to monitor intraoperative nociception as well as for the more classical BIS index for depth of anesthesia. Nevertheless, doses of intravenous PE bolus used in the present study (1 µg kg−1) might be regarded as smaller than more conventional ones (100–200 µg per bolus). Further studies need to be done with the latter doses.

During the perioperative period, nociception control is certainly one of the anesthesiologist's main objectives when assuming care of a patient. There exists some literature demonstrating that the nociceptive stimuli experienced during surgery are responsible for peripheral and central sensitization phenomena, which can in turn lead to persistent postsurgical pain. An individualized approach to the evaluation and treatment of perioperative nociception is beneficial in order to avoid the sensitization phenomena that leads to prolonged postoperative pain and to minimize the consumption of opiates and their adverse effects. In terms of sensitivity, specificity, and positive/negative predictive values when compared to heart rate (HR) and mean arterial pressure (MAP), recent literature has shown that the NOL variation (ΔNOL) is the best index to distinguish noxious from non-noxious stimuli. Chronic treatment with β1-adrenergic antagonists may constitute a limitation to the use of the NOL index. β1-adrenergic antagonists induce a depressive action on the heart rate, which results in a limitation of its variability after a noxious stimulus. Since heart rate and heart rate variability are two parameters integrated into the NOL index, the validity of the NOL index in a population of patients receiving β1-adrenergic antagonists has not yet been determined. Our study sought to explore the NOL index, the BIS, and the heart rate variation in a group of patients under chronic treatment with β1-adrenergic antagonists submitted to standardized noxious stimulus under general anesthesia. We then compared those results to a control group of patients from our previous study (CJA group) that received no β1-adrenergic antagonist chronic treatment. The patients in this study were subjected to a standardized anesthetic protocol from induction up to 3 min after a standardized tetanic stimulus to the ulnar nerve at a frequency of 100 Hz and an amperage of 70 mA, for a duration of 30 s. Data were electronically recorded to obtain NOL, BIS, and heart rate values every 5 s for the duration of the protocol. The NOL maximal mean value reached after noxious stimulation was not different between our two cohorts (CJA: 30(14) versus BETANOL: 36(14) (p = 0.12)). There was no statistically significant difference between our cohorts in regards of the NOL AUC representing the variation of the NOL over a 180 s period (CJA: 595(356) versus BETANOL: 634(301) (p = 0.30)). However, a repeated measurement ANCOVA identified slight statistically significant differences between our cohorts in the peak of variation of the NOL index between 20 and 65 s after noxious stimulation, the NOL index of the cohort of beta-blocked patients being higher than the CJA patients. Moreover, the time to reach the maximum value was not different (CJA: 73(37) versus BETANOL: 63(41) (p = 0.35)). NOL sensitivity and specificity to detect a noxious stimulus under general anesthesia were similar in patients taking beta-blockers or not, and were better than those of heart rate and Bispectral index (AUC NOL 0.97, CI(0.92–1), versus AUC BIS 0.78, CI(0.64–0.89) and AUC HR 0.66, CI(0.5–0.8)). In conclusion, the NOL index is a reliable monitor to assess nociception in a population of patients under chronic beta-blocker therapy. Patients under such therapy achieve similar maximal NOL values over a 180 s period after a standardized noxious stimulus and the NOL variation over time, represented by the AUC is not significantly different from a cohort of non-beta-blocked patients. Whether the patient takes beta-blockers or not, sensitivity of the NOL index is greater than that seen for BIS index or heart rate to detect an experimental noxious stimulus under general anesthesia.

Non-anaesthetists commonly administer procedural sedation worldwide, posing the risk of respiratory events that can lead to severe complications. This study aimed to evaluate whether simulation-based learning could lead to enhancements in the clinical proficiency of non-anaesthesiology residents in managing sedation and related respiratory complications. Following the evaluation of baseline clinical performance through a pre-test simulation, 34 residents were randomly allocated to either participate in an innovative simulation-based learning module (intervention group) or view a brief self-learning video (control group). After a one-month period, their clinical performance was assessed again in a post-test simulation involving respiratory arrest during procedural sedation. Two independent assessors rated each resident’s performance using video recordings and a scoring tool with scores ranging from 0 to 19/19. The two assessments were averaged for each performance, and the pre- to post-test change was calculated for each resident. While baseline clinical performance was similar, mean (SD) increase in clinical performance was significantly greater in the intervention group than in the control group (+2.4 (1.6) points versus +0.8 (1.3) points, respectively; p = 0.002). Our simulation-based learning sedation module resulted in the enhanced management of sedation-related complications compared to baseline and minimal self-learning. Simulation-based medical education may offer an effective approach for equipping non-anaesthesiology residents with essential skills to mitigate risks associated with sedation. (ClinicalTrials.gov identifier: NCT02722226).

Dental surgery includes invasive procedures performed under sedation or monitored anesthesia care (MAC). It is associated with respiratory risks, resulting in death or neurological sequelae without prompt and appropriate management. Management of airway complications also implies mastering crisis resource management (CRM) principles, essentially non-technical skills to improve patient safety. In response to the need to enhance patient safety and to securely perform surgical procedures outside the operating room due to reduced surgical activity during the worldwide spread of the COVID-19 pandemic, we realized, in our simulation center, a course based on high fidelity simulation to teach procedural sedation and management of related complications. The simulation center accredited this educational program as a continuing professional development formation. The course includes technical skills practice, theoretical presentation, and mastering non-technical skills related to CRM principles. This brief report describes a relatively innovative teaching technique in dentistry, highlights its interest, and reports the subjective opinion of learners as to the pedagogical and professional impact of this training. A learner’s satisfaction survey supports the utility of our sedation and CRM programs. A high degree of satisfaction and perceived value reflect robust learners’ engagement. All medical specialties should encourage high-fidelity simulation continuing professional development courses that incorporate technical skills and crisis management principles.

Introduction: We used eye-tracking technology to explore the visual perception of clinicians during a high-fidelity simulation scenario. We hypothesized that physicians who were able to successfully manage a critical situation would have a different visual focus compared to those who failed. Methods: A convenience sample of 18 first-year emergency medicine residents were enrolled voluntarily to participate in a high-fidelity scenario involving a patient in shock with a 3rd degree atrioventricular block. Their performance was rated as pass or fail and depended on the proper use of the pacing unit. Participants were wearing pre-calibrated eye-tracking glasses throughout the 9-min scenario and infrared (IR) markers installed in the simulator were used to define various Areas of Interest (AOI). Total View Duration (TVD) and Time to First Fixation (TFF) by the participants were recorded for each AOI and the results were used to produce heat maps. Results: Twelve residents succeeded while six failed the scenario. The TVD for the AOI containing the pacing unit was significantly shorter (median [quartile]) for those who succeeded compared to the ones who failed (42 [31–52] sec vs. 70 [61–90] sec, p = 0.0097). The TFF for the AOI containing the ECG and vital signs monitor was also shorter for the participants who succeeded than for those who failed (22 [6–28] sec vs. 30 [27–77] sec, p = 0.0182). Discussion: There seemed to be a connection between the gaze pattern of residents in a high-fidelity bradycardia simulation and their performance. The participants who succeeded looked at the monitor earlier (diagnosis). They also spent less time fixating the pacing unit, using it promptly to address the bradycardia. This study suggests that eye-tracking technology could be used to explore how visual perception, a key information-gathering element, is tied to decision-making and clinical performance.